Case NSG 331 (NSG331) Exam 2 study guide Care of the Adult in the Perioperative Setting.

MODULE 3:
Care of the Adult in the Perioperative Setting
Case study
• J.D., a 45-year-old female, presents to the surgeon’s office for presurgical workup for right breast lumpectomy.
• Ambulatory/Outpatient setting and elective goal is cure.
Nurses Role in the pre-op setting
 Knowledge of disorder that requires the surgery along with comorbidities.
 ID patient’s response to stress of surgery
 Knowledge of the results of appropriate preoperative diagnostic tests.
 ID risks and complications
 Knowledge of documentation and communicating of important preoperative assessment findings are essential
for quality care.
 Avoid repetition, know pre-surgery needs
 Interview – one of the most important
 Communicate findings to others
Case Study continued…
• J.D. is accompanied by her husband.
• She tells you she has two school-age children.
• She states that she is here because her breast biopsy was positive for cancer and she anticipates that the
lumpectomy will remove all cancer.
• The nurse should (in the interview)
• Obtains patients’ health history including drug and food allergy
• Provides information and clarifies info about surgery including anesthesia
• Assess the patient’s emotional state and readiness for surgery, including his or her expectations
about the surgical outcome
Case Study Assessment
• J.D. tells you she has a history of hypertension, for which she takes HCTZ daily.
• She recently was diagnosed with type 2 diabetes and is currently controlled with an oral agent and diet.
• The nurse should establish baseline data (vitals, blood sugar, and if she took her meds today or not?)
• Psychological status – reinforce coping strategies
• Physiological status – factors contributing to risk
• Plan of care **safety
Nursing Assessment Goals
** Overall goal is to identify risk factors and plan care to ensure patient safety throughout the surgical experience.
• Establish baseline data for comparison in the intraoperative and postoperative period
• Determine the patient’s psychological status to reinforce the use of coping strategies during the surgical
experience
• Determine physiological factors directly or indirectly related to the surgical procedure that may contribute to
operative risk factors
• Identify and document surgical site
• Identify drugs, OTC medications, and herbs taken that may affect surgical outcome
• Review results of preoperative diagnostic studies
• Identify cultural and ethnic factors that may affect surgical experience
• Determine receipt of adequate information from surgeon to sign informed consent
• Determine that consent form is signed and witnessed and if given enough info

Psychosocial assessment
• Excessive stress response can be magnified and affect recovery
• Influencing factors
• Age
• Past experiences

, • Current health
• Socioeconomic status
• Use common language & avoid medical jargon
• Use translators if needed because familiar language…
• Decreases level of anxiety
• Communicate all concerns to surgical team
• Nurse’s role is to assess the patient for potential or actual stressors that could negatively affect surgery.
• Most common psychological factors are ANXIETY, FEAR, AND HOPE
• Anxiety can impair cognition, decision making, and coping abilities
• Anxiety can arise from
• Lack of knowledge
• Unrealistic expectations
 Stories heard in media and/or by friends
• Information lessens anxiety
• Inform the physician if any further information is needed or if anxiety is excessive
• Anxiety may arise from conflict with interventions (i.e., Jehovah’s witness and blood transfusions) and religious
or cultural beliefs
• Identify beliefs and discuss with surgeon and operative staff
Case study continued…
• J.D. states that her mother and aunt have a history of breast cancer resulting in mastectomy.
• She appears anxious and you note constant fidgeting.
• J.D. states that she is here because her breast biopsy was positive for cancer.
• She anticipates that the lumpectomy will remove all cancer.
• She has had no other surgeries.
Psychosocial Assessment continued…
• Fears
• Death or disability
 Notify the HCP if severe because it may prompt postponement
 Influence outcome
• Pain
 Consult with ACP
 Reassure the patient that drugs are available for anesthesia and analgesia during surgery – will
not lead to addiction
 Confirm drugs will be available and encourage patient to ask before pain becomes severe!
 Teach the patient how to use a pain intensity scale.
• Mutilation/alteration in body image
 Assess concerns nonjudgmentally
 Can happen in both radical (amputation) and minor (breast biopsy) surgeries.
• Anesthesia
 ACP for consult
 May arise from fear of the unknown, personal experiences, or tales of other bad experiences.
 Many fear losing control while under anesthesia, or brain damage/paralysis
• Disruption of life functioning
 Range from fear of permanent disability to temporary loss
 Include family and financial concerns
 Consultations PRN w/ caregiver, social worker, psychologist or financial advisor
• Hope
• May be strongest positive coping mechanism
• Never deny/minimize b/c it could negate positive mental attitude necessary for a quick and full recovery
• Repair (plastic surgery for burns), rebuild (total joint replacement) or save/extend a life (repair of an
aneurysm or transplant)
• Assess and support

,Case study continued…
• J J.D. is currently taking HCTZ, glipizide (Glucotrol), multivitamin, fish oil, and a daily low-dose aspirin.
• She reports an allergy to penicillin, resulting in a rash.
• Nursing concerns
• HTN, hypoglycemia, bleeding from aspirin and fish oil, PCN allergy considered, and latex allergy,
fish oil can raise fasting glucose levels
• All OTC drugs, herbs, recreational drugs, and tobacco
Past Health history
 Previous health problems and surgeries
o Does patient understand need for surgery?
 Ex. Patient schedule for a total knee replacement may indicate it is because increasing pain and
immobility
 Document the reason for past hospitalizations
o Including past surgeries and dates.
o Identify any problems with previous surgeries
 Ex wound infection or drug reaction
 Ask women about menstrual cycle and obstetric history
o Date of last period, number of pregnancies, history of C sections
Family health history
 Any inherited traits?
 Parent with heart and/or endocrine disease
o Ex. HTN, sudden cardiac death, or MI
 Adverse reactions to or problems with anesthesia
o Ex. Malignant hyperthermia has a genetic predisposition. Measures can be used to decrease
complications associated with this condition can be taken.
Medications
 The interaction of the patient’s current drugs and anesthetics can increase or decrease the desired physiological
effect of the anesthetics.
o Opiods and prescribed drugs for chronic health conditions (heart disease, HTN, depression, seizure
disorder, DM)
 Antidepressants – can potentiate the effect of opioid agents that can be used for anesthesia
 Antihypertensive – may predispose the patient to shock from the combined effect of the drug
and the vasodilator effect of some anesthetic agents
 Insulin – may require adjustments during the perioperative period because of increased
metabolism, decreased oral intake, stress, and anesthesia
 Antiplatelet – inhibit platelet aggregation and may contribute to postoperative bleeding
o Surgeons may instruct patients to withhold these drugs before surgery
 The drugs below present a problem:
 Longterm anticoagulant therapy (warfarin)
 Rivaroxaban (Xarelto)
 Dabigatran (Pradaxa)
 Apixaban (Eliquis)
 The options for patients taking this medication are determined by patient history and
nature of surgery and include:
o Continuing therapy
o Withholding for a time before and after surgery
o Withholding the therapy and starting subcutaneous or IV heparin therapy during
the perioperative period.
o Herbs and dietary supplements – discontinue 2-3 weeks prior to surgery
 They can cause harmful effects

,  Patient taking anticoagulants and antiplatelets, herbal supplements can produce excessive
postoperative bleeding that may require a return to the OR.
 Avoid:
 Astragalus and ginseng – raise BP before and during surgery
 Garlic, Vitamin E, gingko, and fish oils – increase bleeding
 Kava and valerian – cause excessive sedation
o Recreational drugs (alcohol, tobacco, opioids, marijuana, cocaine, and amphetamines)
 Stress that recreational drugs use may affect the type and amount of anesthesia.
 When patients become aware of risks they will usually be truthful.
 Chronic alcohol – potential lung, liver, and GI damage.
 Liver function decrease, metabolism of anesthetic agents is prolonged, nutritional status
is altered, and the potential for postoperative complications increases.
 Alcohol withdrawal can also occur.
Allergies
 Drug intolerance and drug allergies
 Document and put an allergy arm band on patient when necessary
 Also include nondrug allergies (food, latex, pollen, animals)
 Patients with a history of allergic reactions are more at risk for hypersensitivity to drug given in anesthesia.
 Latex allergy
o Risks factors – long-term, multiple exposures to latex (health care and rubber industry), hay fever,
asthma, and food allergies to eggs, avocado, bananas, chestnuts, potatoes, and peaches)
Review of systems
• Body systems review
o Confirms the presence or absence of diseases
o Alerts to areas to closely examine
o Provide essential data to determine specific preoperative tests
o Confirms the presence or absence of diseases
o Alerts to areas to closely examine
o Provide essential data to determine specific preoperative tests
o RESULTS SHOULD BE IN CHART BEFORE SURGERY
• Cardiovascular system
o Report
 Any cardiac problems so they can be monitored during the intraoperative period
• HTN, angina, dysrhythmias, heart failure, or MI
 Cardiac consult for recent MI, valvular heart disease, implantable cardioverter - defibrillator
 Inquire about current treatment and level of functioning
• Presence of pacemaker/ICD or use of cardiac drugs
o 12-lead electrocardiogram (ECG) – results in chart prior to surgery
o Coagulation studies – results in chart prior to surgery
o CV assessment provides what other data on what other measures need to be done
 Ex. Patient on diuretic therapy needs potassium levels drawn
 Ex patient with history of HTN, may need vasoactive drugs to maintain BP during surgery
 Ex. Patient with prosthetic heart valve may need prophylactic antibiotics to reduce endocarditis
risk
 Venous thromboembolism (VTE) prophylaxis
• TED hose and SCDs
• Respiratory system
o Inquire about recent airway infections
 Procedure could be cancelled because of increased risk of laryngo/bronchospasm, decreased
SaO2, or problems with respiratory secretions.
o History of dyspnea, coughing, or hemoptysis reported to operative team (ACP and surgeon)